Patient Satisfaction and Quality of Care: Are They Linked?

Since the 1980s, interest in the measurement of patients' satisfaction with their healthcare experiences has increased, following reports that high patient satisfaction is associated with better health outcomes. This has not been universally accepted, however, and the debate over using patient satisfaction ratings as a quality-of-care marker continues.

In March 2012, a study published in Archives of Internal Medicine made a controversial contribution to the debate. Joshua J. Fenton, MD, MPH, and colleagues at the University of California, Davis, reported the results of their analysis of data from more than 50,000 adult patients indicating that the most satisfied patients (highest patient satisfaction quartile relative to the lowest quartile) were 12% more likely to be admitted to the hospital and had both total healthcare expenditures and prescription drug expenditures that were 9% higher. Most perplexing to many readers at the time, these patients were also 26% more likely to die.

These findings were derived from assessments of patient satisfaction based on 5 items from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey and healthcare utilization (any emergency department visits and any inpatient admissions) 1 year later. The data came from respondents to the 2000-2007 national Medical Expenditure Panel Survey.

Among the strengths of the study were its nationally representative sample and adjustment for potential confounders, such as sociodemographic characteristics, insurance status, availability of a usual source of care, chronic disease burden, health status, and first-year healthcare utilization and expenditures. These adjustments were the basis for some immediate and later criticisms of the study, which cited other studies that found higher patient satisfaction associated with favorable outcomes, including lower inpatient mortality rates.In reply, Dr. Fenton and his coauthors pointed out that when they excluded the sickest 5% of patients who reported high satisfaction from their analysis, the association between higher satisfaction and mortality grew even stronger.

Since publication, Dr. Fenton's findings, particularly the mortality association, have been cited many times in the medical and lay press as evidence in support of the view that patient satisfaction is not associated with quality-of-care outcomes, including a recent article reprinted by Medscape that attracted many comments in agreement. The study also continues to garner criticism from supporters of the opposite view.